Pediatric ERCP Positioning Can Impact Anesthesia Time

Research study background

Endoscopic retrograde cholangiopancreatography (ERCP) combines endoscopy and fluoroscopy to diagnose and treat bile and pancreatic duct conditions, such as choledochal cysts and chronic pancreatitis. Unlike adults, who often undergo ERCP without general anesthesia, pediatric patients require intubation and deep sedation. They are typically intubated in the supine (face-up) position, turned to prone for the procedure and then returned to supine for extubation. These steps prolong overall anesthesia time and may increase certain risks.

“In children, especially, there are concerns for the neurodevelopmental impact of anesthesia, so any ability to decrease exposure is important,” says lead study author Robert Kramer, MD, Director of Endoscopy, Digestive Health Institute at Children’s Hospital Colorado.

In recent years, the Pediatric Pancreas Center within the Digestive Health Institute changed practice to adopt supine positioning for pediatric ERCP. This study is the first of its kind to assess pediatric patient positioning for ERCP procedural outcomes and anesthesia time.

The research team retrospectively reviewed all ERCPs at Children’s Colorado between September 2016 and August 2023. Procedures were performed by Dr. Kramer or Jacob Mark, MD, co-author of the study. The final cohort included 378 ERCPs — 198 initially supine and 180 initially prone — performed on 283 patients ranging in age from under 1 to 25 years old.

Supine positioning was associated with an initial 9.3 minute decrease in total anesthesia, compared to prone. The endoscopists’ learning curve was between 10 and 40 cases. After they mastered the supine technique, there were further benefits to efficiency: The mean procedure time decreased by 11 minutes and the total anesthesia time decreased by 16 minutes. Additional procedures under the same anesthesia, native papilla and longer total procedure time were independently associated with increased anesthesia time. Both positions achieved high ERCP success rates, with no significant differences in post-ERCP pancreatitis (PEP), unintentional pancreatic duct cannulation for biliary ERCPs, or procedural time.

These results demonstrate that supine ERCP decreased anesthesia time with no significant sacrifices to safety or cannulation success compared to prone position.

“By showing that these procedures can be performed in the supine position, with the anticipated decrease in total procedure and anesthesia time and without decrease in success rates or more complications, we can begin to change standard practice, decrease costs and anesthesia time in children,” Dr. Kramer says.

Relevance to future research

The study authors presented their findings at national pediatric gastroenterology meetings to highlight the safety and efficacy of supine positioning for pediatric ERCP and encourage broader adoption. Future multicenter studies should be conducted to validate these findings and evaluate long-term neurodevelopmental outcomes related to anesthesia exposure.